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Personal Insurance Homeowner Fact Finder
Personal Insurance Homeowner Fact Finder
Date
*
MM slash DD slash YYYY
How did you hear about Avery Insurance?
Primary Insurance Holder Information
Name
*
First
Last
Mailing Address
*
Street Address
Address Line 2
City
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State
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How long have you been at your current address?*
How long have you been at your current address?
Please enter a number from
0
to
100
.
Months
*
Months
1
2
3
4
5
6
7
8
9
10
11
Phone Number
*
Untitled
*
Home
Cell
Business
Email
*
Marital Status
Please Select
Single
Married
Divorced
Widowed
DOB
*
MM slash DD slash YYYY
Occupation
Secondary Insurance Holder (if applicable)
Name (Secondary)
First
Last
Phone
Untitled
Home
Cell
Business
Email
DOB
MM slash DD slash YYYY
Occupation
Marital Status
Please Select
Single
Married
Divorced
Widowed
Property Information
Property Location (if different from mailing address)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How long have you owned this property?
How long have you owned this property?
Please enter a number from
0
to
100
.
Months
Months
1
2
3
4
5
6
7
8
9
10
11
If less than 3 years please provide previous address:
*
Is this a new purchase?
Yes
No
What is the closing date:
MM slash DD slash YYYY
Is there a mortgage?
Yes
No
What is the bank name?
What is the bank payor?
What is the bank address?
What is the usage of the property?
*
Please Select
Primary Home
Secondary Home
Seasonal Home
Rental Home
Year Built
*
Style
Number of stories:
Total square feet
*
Value
*
Type of construction
*
Please Select
Wood Frame
Masonry
Log
Other
Other
*
Type of heating/fuel
*
Please Select
Electrical
Oil
Gas
Other
Location of oil tank (if applicable)
Type of electrical system
*
Please Select
Circuit Breaker
Fuses
Nob & Tube
Other
Number of amps (if applicable)
Approximate year of updates on the systems below (for buildings 20 years and older)
Heating
Plumbing
Wiring
Roofing
If the house was built prior to 1930, what are the wall partitions constructed of?
Please Select
Drywall
Plaster
Mix of Drywall and Plaster
Does your kitchen have any custom features? (i.e. granite, customer cabinets, high end appliances, etc.)
Yes
No
Please list these features:
How many bathrooms?
Any custom bathroom features?
Yes
No
Please list these features:
What is the roof type?
*
What is the siding material?
*
Do you have a basement?
Yes
No
Please check all that apply.
Finished Basement
Partially Finished
Walkout
Drain
Sump Pump
Do you have a garage?
Yes
No
What type of garage?
Attached
Detached
Do you have any outbuildings or other structures?
Yes
No
Please list:
Is there a fire hydrant within 1,000 ft of your home?
Yes
No
Is there a central burglar or fire alarm?
Yes
No
What kind of alarm?
Additional Information
Pets?
*
Yes
No
Please list the types and the breed(s):
*
Any bite history?
*
Yes
No
Please describe:
*
Any obedience training?
*
Yes
No
Please describe:
*
Pool?
*
Yes
No
Please check all that apply.
*
Above ground
Inground
Fenced
Slide
Diving board
Trampoline?
*
Yes
No
Is it enclosed?
*
Yes
No
Is there any type of business conducted in your home?
Yes
No
Please describe:
Do you have customers come to your home?
Yes
No
Please describe:
Do you employ any domestic staff?
Yes
No
Please describe:
Do you have any special items (such as jewelry, fine arts or musical instruments) that you would like to insure separately?
Yes
No
Please provide a brief description and approximate value:
Do you belong to a homeowner or condo association?
Yes
No
Which association(s)?
Do you currently have a personal umbrella/excess liability coverage?
Yes
No
What are your current insurance limits?
Any prior losses/claims? (From current home or other locations.)
*
Yes
No
Please provide date and description:
*
Has your insurance been canceled or non-renewed in the past 3 years?
*
Yes
No
Please describe:
*
Any bankruptcy(s) in the past 5 years?
*
Yes
No
Please describe:
*
Would you like any information on the following? Oftentimes, combining different lines of business with one insurance company result in premium savings
Auto insurance
Boat insurance
Personal insurance
Umbrella insurance
Excess liability
Recreational vehicle insurance
Earthquake insurance
Flood insurance
Business
Life
Health
Other
Other
Who is your current insurance carrier?
Policy expiration date:
MM slash DD slash YYYY
Additional comments:
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